Blue Plus Minnesota Value Gold $1000 Plan 405 – PPO

Network type: PPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $60 copay
Urgent care visit: $20 copay

Description

Health Care Plan Details

Network type PPO
Deductible $1,000 per person $1,000 per person
Out-of-pocket max $8,000 per person $16,000 per family
Metal tier Gold

Visit Copay

Primary care visit $20 copay
Specialist visit $60 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $20 copay
Emergency room 20% after deductible
Ambulance 20% after deductible
Hospital stay (facility) 20% after deductible
Hospital stay (physician) 20% after deductible
Outpatient procedure (facility) 20% after deductible
Outpatient procedure (physician) 20% after deductible
Physical rehabilitation 20% after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay 20% after deductible

Pharmacy, Drugs, and Medication

Generic $20 copay
Brand 20% after deductible
Non-preferred Brand 40% after deductible
Specialty $650 copay

Lab Tests and Diagnostic Procedures

X-rays 20% after deductible
Imaging (CT/PET/MRI) 20% after deductible
Blood work 20% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $20 copay
Psychiatric hospital stay 20% after deductible

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/Hpwt8DYKrbCyzpNkn8JvTFfk.pdf